CEO Financial Literacy Academy

First Name

Last Name

Phone Number

E-mail

Address

Address Line 1

Address Line 2

City

State

Zip Code

Free or Low-Cost Service

Are you interested in a Free Smartphone or Tablet?

Yes
No

Do you currently have Health Insurance?

Yes
No

If Yes then Please give the name of Carrier

Eligibility and Background:

Are you currently employed?

Yes
No

Have you been laid off from your job?

Yes
No

Have you registered with Selective Service?

Yes
No

Are you currently or have you ever been in the U.S. Military?

Yes
No

Are you married to an active/inactive member of the U.S. Military?

Yes
No

Are you a Veteran or Vietnam Veteran?

Yes
No

Governmental Assistance:

Are you currently receiving any of the following types of governmental assistance?

Are you currently collecting unemployment benefits?

Yes
No

Are you a custodial parent or expectant mother?

Yes
No

Are you a Refugee or non-citizen?

Yes
No

Are you a U.S. citizen?

Yes
No

Are you a victim of domestic violence?

Yes
No

Employment and Education:

Are you currently paying or delinquent in child support?

Yes
No

Are you currently enrolled in school or training?

Yes
No

Do you have any educational certificates?

Yes
No

Do you have any training certificates?

Yes
No

Transportation and Accessibility:

Do you use public transportation?

Yes
No

Do you have any special needs that require reasonable accommodations?

Yes
No

Do you have any special skills (e.g., typing, computer programs, etc.)?

Yes
No

Services You Are Interested In:

I am interested in Job Assistance:

Yes
No

I am interested in Training Assistance:

Yes
No

I am interested in Resume Assistance:

Yes
No

I am interested in GED Assistance:

Yes
No

I am interested in Filing for Unemployment Compensation:

Yes
No

I am interested in Employability Skills Assistance:

Yes
No

I am interested in Transportation Assistance:

Yes
No

I am interested in Expunge and Seal Assistance:

Yes
No

I am interested in Childcare Assistance:

Yes
No

Additional Comments or Questions:

Upload Photo ID or Driving License:

Click or drag a file to this area to upload.

Participant Signature:

Clear Signature

Date

New Client Intake Form